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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF rCE US : 1601 E. Hazelton, Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> k <br /> A (Complete In Triplicate) - s <br /> pplication i her made, to the San Joaquin Local Health Distric <br /> t for a permit to construct <br /> and/or instal the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the.Rules- and Regulations of the San Joaquin Local Health District. { <br /> .TOB ADDRESS/LOCATION Vr r <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ,zri City <br /> Contractor's Name 21% 2" , a . , License # 14LPhone b `,�s <br /> TYPE OF WORK (Check) : NEW 2LL''% / DEEPEW/_/ RECONDITION /�% DESTRUCTION /_7 <br /> PUMP INSTALLATION I I PUMP REPAIR <br /> / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK., .SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> V <br /> INTENDED USE <br /> TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation s <br /> Domestic/private Drilled k <br /> Dia: ,of Well Casing <br /> Domestic/public Driven Gauge-of, CasingIrri <br /> Irrigation GravelPack <br /> Depth of Grou <br /> Other Rotary t Seal <br /> Type of Grout . \4, <br /> n J k <br /> Other Other Information <br /> n� k I <br /> PUMP INSTALLATION: Contractor �� <br /> Type of Pump <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / / State Work Dane �� yL L) <br /> Zj <br />.DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after 'completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED , <br /> TITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE),-- r <br /> FO DEPARTMEN USE ONLY <br /> PHASE .I � � � ' <br /> APPLICATION ACCEPTED BY l -� <br /> ADDITIONAL COMMENTS: <br /> 1100' J <br /> PHASE II GROUT INSP CTION PHASE I I/FWAL INSPECTION <br /> INSPECTION BY DATE NSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION FRIO 0 GROUTING AND 'FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />